Asthma Clinical Guidelines - Asthma Community …...Asthma Clinical Guidelines Adapted from the...

Asthma Clinical Guidelines

Adapted from the National Heart, Lung, and Blood Institute’s (NHLBI) National Asthma Education and Prevention Program (NAEPP) 2007 Expert Panel Report 3:

Guidelines for the Diagnosis and Management of Asthma Goals of Asthma Treatment

Patients will: • Be free from troublesome symptoms day and night, including sleeping through the night.

• Have the best possible lung function. • Be able to participate fully in any activities of their choice. • Not miss work or school because of asthma symptoms. • Need fewer or no urgent care visits or hospitalizations for asthma. • Use medications to control asthma with as few side effects as possible. • Be satisfied with their asthma care.

It is also important to determine the patient’s personal treatment goals and preferences for treatment. Ask how asthma interferes with the patient’s life (e.g., inability to sleep through the night, play a sport), and incorporate the responses into personal treatment goals. Involve the patient in decision-making about treatment.

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Referral to an Asthma Specialist

Based on the opinion of the Expert Panel, referral for consultation or care to a specialist in asthma care is recommended when:

• Patient has had a life-threatening asthma exacerbation.

• Patient is not meeting the goals of asthma therapy after 3-6 months of treatment, or is unresponsive to therapy.

• Signs and symptoms are atypical, or there are problems in differential diagnosis.

• Other conditions complicate asthma or its diagnosis (e.g., sinusitis, nasal polyps, aspergillosis, severe rhinitis, VCD, GERD, COPD).

• Additional diagnostic testing is indicated (e.g., allergy skin testing, pulmonary function studies, provocative challenge, bronchoscopy).

• Patient requires additional education and guidance on complications of therapy, problems with adherence, or allergen avoidance.

• Patient is being considered for immunotherapy.

• Patient requires step 4 care or higher (step 3 for children 0-4 years of age). Consider referral if patient requires step 3 care (step 2 for children 0-4 years of age).

• Patient has required more than two bursts of oral corticosteroids in 1 year or has an exacerbation requiring hospitalization.

• Patient requires confirmation of a history that suggests that an occupational or environmental inhalant or ingested substance is provoking or contributing to asthma.

An asthma specialist is usually a fellowship-trained allergist or pulmonologist or, occasionally, a physician with expertise in asthma management developed through training and experience. Patients with significant psychiatric, psychosocial, or family problems that interfere with their asthma therapy should be referred to an appropriate mental health professional for counseling or treatment.


Differential Diagnosis for Asthma

Infants and Children Upper airway diseases

• Allergic rhinitis and sinusitis Obstruction involving large airways

• Foreign body in trachea or bronchus • Vocal cord dysfunction • Vascular ring or laryngeal web • Laryngotracheomalacia, tracheal stenosis, or bronchostenosis • Enlarged lymph nodes or tumor

Obstructions involving small airways • Viral bronchiolitis or obliterative bronchiolitis • Cystic fibrosis • Bronchopulmonary dysplasia • Heart disease

Other Causes • Recurrent cough not due to asthma • Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux

Adults • Chronic Obstructive Pulmonary Disease (COPD) (e.g., chronic bronchitis or emphysema) • Congestive heart failure • Pulmonary embolism • Laryngeal dysfunction • Mechanical obstruction of the airways (benign and malignant tumors) • Pulmonary infiltration with eosinophilia • Cough secondary to drugs [angiotensin-converting enzyme (ACE) inhibitors] • Vocal cord dysfunction (VCD)

Referral to an Asthma Specialist / Differential Diagnosis for Asthma


* Level of severity is determined by both impairment and risk. Assess impairment domain by patient’s/caregiver’s recall of the previous 2-4 weeks and spirometry (if ≥5yrs of age). Severity may be assigned to the most severe category in which any feature occurs.

† Risk factors for developing persistent asthma among infants and young children who had four or more episodes of wheezing in the past year that lasted more than (1) one day and affected sleep: either (1) one of the following: parental history of asthma, a physician diagnosis of atopic dermatitis, or evidence of sensitization to aeroallergens, or (2) two of the following: evidence of sensitization to

foods, >4 percent peripheral blood eosinophilia, or wheezing apart from colds. ‡ At present, there are inadequate data to correspond frequency of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (e.g., requiring urgent,

unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients ≥5yrs of age who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.

1 Short-acting inhaled beta2-agonist. 2 Does not include SABA for prevention of exercise-induced bronchospasm.

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SSeevveerriittyy** Intermittent Mild Moderate Severe

Daytime symptoms ≤2 days/week >2 days/week but not daily Daily Throughout

the day Nighttime awakenings None <2x/month 1-2x/month 3-4x/month 3-4x/month >1x/week >1x/week 7x/week

SABA1 use for symptom control2 ≤2 days/week >2 days/week but not daily Daily Several times per day

Interference with normal activity None Minor limitation Some limitation Extremely limited

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Lung function 5-11yrs

Normal FEV1 between exacerbations

FEV1>80% predicted FEV1/FVC>85%

FEV1>80% FEV1/FVC>80%

FEV1=60-80% FEV1/FVC=75-80%

FEV1<60% FEV1/FVC<75%

0-4yrs: ≥2 exacerbations in 6 months requiring oral corticosteroids, or ≥4 wheezing episodes/year lasting >1 day AND risk factors for persistent asthma† RRiisskk Exacerbations requiring

oral corticosteroids 0-1/yr 5-11yrs: ≥2 exacerbations in 1 year requiring oral corticosteroids‡

Classifying Asthma Severity <12 years (The Chronic Disease)

PPeerrssiisstteenntt 5-11yrs – specific for 5-11 years

<12yrs – relevant for all ages 0-4yrs – specific for 0-4 years


Stepwise Approach to Management 0-4 & 5-11 years

Step 1 Preferred: SABA prn

Step 2 Preferred:

Low-dose ICS

Alternative: Cromolyn,

Montelukast (LTRA)

Step 3 Preferred

Medium-dose ICS

Step 5 Preferred: High-dose

ICS + LABA

Step 6 Preferred: High-dose

ICS Step 4

Preferred: Medium-dose ICS + LABA

Persistent Each Step: Patient education, environmental control, management of co-morbidities Once the patient has achieved control, classify based on the amount of therapy required to maintain control. Steps 2-4: Consider subcutaneous allergen immunotherapy for patients ≥5yrs of age with persistent allergic asthma.

Moderate Severe

Step up if needed (first, check

adherence, inhaler technique,

environmental control, and co-

morbid conditions)

Mild

Consider Consult

Recommend Consult (0-4 yrs)


5-11yrs – specific for 5-11 years


Nedocromil or Theophylline

Alternative: Medium-dose ICS + either

LTRA or Theophylline

or Montelukast or Montelukast

Alternative:

High-dose ICS + either

LTRA or Theophylline

+ LABA + OCS

Alternative: substitute LTRA or

Theophylline for LABA

+ either LABA or Montelukast

+ OCS

Or Low-dose ICS +

either LABA, LTRA or

Theophylline

Intermittent

Step down if possible

(and asthma is well controlled at least 3

months)

Assess control

The stepwise approach is meant to assist, not replace, clinical decision-making required to meet individual needs.

Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. ICS = inhaled corticosteroid; OCS = oral systemic corticosteroids; LABA = inhaled long-acting beta2-agonist; LTRA = leukotriene receptor antagonist; SABA = inhaled short-acting beta2-agonist

Classifying Asthma Severity <12 years (The Chronic Disease) / Stepwise Approach to Management 0-4 & 5-11 years

Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. ICS = inhaled corticosteroid; OCS = oral systemic corticosteroids; LABA = inhaled long-acting beta2-agonist; LTRA = leukotriene receptor antagonist; SABA = inhaled short-acting beta2-agonist

Step 2

Step 3

Step 5

Step 6

Step 4

PersistentEach Step: Patient education, environmental control, management of co-morbidities Once the patient has achieved control, classify based on the amount of therapy required to maintain control. Steps 2-4: Consider subcutaneous allergen immunotherapy for patients ≥5yrs of age with persistent allergic asthma. The stepwise approach is meant to assist, not replace, clinical decision-making required to meet individual needs.

Moderate Severe

Step up if needed (first, check

adherence, inhaler technique,

environmental control, and co-

morbid conditions)

Step down if possible

(and asthma is well controlled at least 3

months)

Assess control

Mild Intermittent

Consider Consult



5-11 yrs Preferred: High-dose

ICS + LABA + OCS

Alternative: High-dose ICS + LTRA or Theophylline +

OCS

5-11yrs Alternative: Cromolyn, LTRA,

Nedocromil or Theophylline

0-11yrs Preferred: Low-dose ICS

0-4yrs Alternative: Cromolyn,

Montelukast

0-4 yrs: Medium-dose

ICS

5-11 yrs: Medium-dose

ICS or Low-dose ICS + LABA, LTRA or Theophylline

5-11 yrs Preferred:

Medium-dose ICS + LABA

Alternative: Medium-dose ICS

+ LTRA or Theophylline

0-4 yrs: Medium-dose ICS + LABA or Montelukast 5-11 yrs

Preferred: High-dose

ICS + LABA Alternative: High-dose

ICS + either LTRA or

Theophylline

0-4 yrs High-dose

ICS + LABA or Montelukast

0-4 yrs: High-dose

ICS + either LABA

or Montelukast + OCS

Step 1

0-11yrs: SABA prn



<12yrs – relevant for all ages

Classifying Asthma Severity <12 years (The Chronic Disease) / Stepwise Approach to Management 0-4 & 5-11 years

Stepwise Approach to Management 0-4 & 5-11 years


PPeerrssiisstteenntt CCoommppoonneennttss ooff SSeevveerriittyy**

Intermittent Mild Moderate Severe Daytime symptoms ≤2 days/week >2 days/week but not daily Daily Throughout the day

Nighttime awakenings ≤2x/month 3-4x/month >1x/week 7x/week SABA1 use for symptom

control 2 ≤2 days/week >2 days/week but not daily Daily Several times per day

Activity limits None Minor limitation Some limitation Extremely limited


Normal FEV1/FVC: 8-19 yrs 85% 20-39 yrs 80% 40-59 yrs 75% 60-80 yrs 70% Lung function

Normal FEV1 between exacerbations

FEV1>80% FEV1/FVC=normal

FEV1>80% FEV1/FVC=normal

FEV1=60-80% FEV1/FVC

reduced 5%

FEV1<60% predicted FEV1/FVC

reduced >5%

Relative annual risk of exacerbations may be related to FEV1 RRiisskk Flares needing OCS

0-1/yr ≥2 exacerbations in the past year requiring oral corticosteroids†

Classifying Asthma Severity ≥12 years (The Chronic Disease)

* Level of severity is determined by assessment of both impairment and risk. Assess impairment domain by patient’s/caregiver’s recall of previous 2-4 weeks and spirometry. Severity may be assigned to the most severe category in which any feature occurs.

† At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.

1 Short-acting inhaled beta2-agonist 2 Does not include SABA for prevention of exercise-induced bronchospasm


Stepwise Approach to Management ≥12 years

Mild Moderate Severe

Step 1 Preferred:

Step 3 Preferred:

Low-Dose ICS + LABA

OR Medium-Dose ICS

Alternative: Low-Dose ICS

+ either LTRA,

Theophylline, or Zileuton

Step 4 Preferred:

Medium-Dose ICS + LABA

Alternative:

Medium-Dose ICS + either

LTRA, Theophylline or Zileuton

Step 5 Preferred: High-Dose

ICS + LABA

And Consider

Omalizumab for patients who have

allergies

Step 6 Preferred:

High-Dose ICS + LABA +

Oral Systemic Corticosteroid

And

Consider Omalizumab for

patients who have allergies

Step Up if needed

(first, check adherence, inhaler

technique, environmental

control, and co-morbid conditions)

Step down if

possible (and asthma is well controlled at least 3

months)

RReeccoommmmeenndd CCoonnssuulltt

CCoonnssiiddeerr CCoonnssuulltt

Assess Control

SABA prn

Step 2 Preferred:

Low-Dose ICS

Alternative: Cromolyn,

LTRA, Nedocromil, or

Theophylline

Each Step: Patient education, environmental control, and management of co-morbidities Once the patient has achieved control, classify based on the amount of therapy required to maintain control. Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have persistent allergic asthma. The stepwise approach is meant to assist, not replace, clinical decision-making required to meet individual needs.

• If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up. • In Step 6, before oral systemic corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or zileuton may be considered, although this

approach has not been studied in clinical trials. • Immunotherapy for steps 2-4 based on evidence may be most helpful for those with house dust mite, animal dander or pollen allergy; evidence is weak or lacking for molds

and cockroaches. Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. ICS = inhaled corticosteroid; LABA = inhaled long-acting beta2-agonist; LTRA = leukotriene receptor antagonist; OCS = oral corticosteroid; SABA = inhaled short-acting beta2-agonist

Classifying Asthma Severity ≥12 years (The Chronic Disease) / Stepwise Approach to Management ≥12 years


The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient’s/caregiver’s recall of previous 2-4 weeks and by spirometry or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether patient’s asthma is better or worse since the last visit. * ACT = Asthma Control Test (recommended by MaineHealth AH! Asthma Health Program for children 4-11yrs).

CCoommppoonneennttss ooff CCoonnttrrooll

Well Controlled Not Well Controlled Very Poorly Controlled

Daytime symptoms ≤2 days/week but not more than once on each day

>2 days/week or multiple times on ≤2 days/week

Throughout the day

Nighttime awakenings ≤1x/ month

≤1x/ month

>1x/ month

≥2x/ month

>1x/ week

≥2x/ week

Short-acting beta2-agonist use (not

prevention of EIB) ≤2 days/week >2 days/week Several times

per day

Activity limits None Some limitation

Extremely limited

Validated questionnaire: ACT* (4-11yrs) ≥20 16-19 ≤15


Lung function FEV1 or PEF>80% FEV1/FVC>80%

FEV1 or PEF=60-80% FEV1/FVC=75-80%

FEV1 or PEF<60% FEV1/FVC<75%

RRiisskk OCS use 0-1/year 2-3/year >3/year • Step up (1 step); and • Re-evaluate in 2-6 weeks • For side effects, consider alternative treatment options

• Consider short course of oral systemic corticosteroids • Step up (1-2 steps); and • Re-evaluate in 2 weeks • For side effects, consider alternative treatment options

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• Maintain current step • Regular follow-up every 1-6 months • Consider step down if well controlled for at least 3 months

• If no clear benefit in 4-6 weeks, consider alternative diagnoses or adjusting therapy


Determining Asthma Control <12 years


<12yrs – relevant for all ages 0-4yrs – specific for 0-4 years CCllaassssiiffiiccaattiioonn ooff AAsstthhmmaa CCoonnttrrooll

The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient’s/caregiver’s recall of previous 2-4 weeks and by spirometry or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether patient’s asthma is better or worse since the last visit. * NHLBI (www.nhlbi.nih.gov) recommendations separate age groups for nighttime symptoms. Age groups have been combined for ease of application. ** ACT = Asthma Control Test (recommended by MaineHealth AH! Asthma Health Program for children 4-11yrs).

CCoommppoonneennttss ooff CCoonnttrrooll


Daytime symptoms ≤2 days/week but not more than once on each day

>2 days/week or multiple times on ≤2 days/week

Throughout the day

Nighttime awakenings * ≤1x/ month

≥2x/ month

≥2x/ week

Short-acting beta2-agonist use (not

prevention of EIB) ≤2 days/week >2 days/week Several times

per day

Activity limits None Some limitation

Extremely limited

Validated questionnaire: ACT** (4-11yrs) ≥20 16-19 ≤15


Lung function FEV1 or PEF>80% FEV1/FVC>80%

FEV1 or PEF=60-80% FEV1/FVC=75-80%

FEV1 or PEF<60% FEV1/FVC<75%

RRiisskk OCS use 0-1/year 2-3/year >3/year • Step up (1 step); and • Re-evaluate in 2-6 weeks • For side effects, consider alternative treatment options

• Consider short course of oral systemic corticosteroids • Step up (1-2 steps); and • Re-evaluate in 2 weeks • For side effects, consider alternative treatment options


• Maintain current step • Regular follow-up every 1-6 months

• Consider step down if well controlled for at least 3 months



Determining Asthma Control <12 years

CCllaassssiiffiiccaattiioonn ooff AAsstthhmmaa CCoonnttrrooll5-11yrs – specific for 5-11 years



CCllaassssiiffiiccaattiioonn ooff AAsstthhmmaa CCoonnttrrooll CCoommppoonneennttss ooff CCoonnttrrooll


Daytime symptoms ≤2 days/week >2 days/week Throughout the day

Nighttime awakenings ≤2x/month 1-3 x/week ≥4x/week

Short-acting beta2-agonist use (not prevention of EIB) ≤2 days/week >2 days/week Several times per day

Activity limits None Some limitation Extremely limited

Lung function FEV1 or PEF>80% FEV1 or PEF=60-80% FEV1 or PEF<60%


Validated questionnaire: ACT ≥20 16-19 ≤15

RRiisskk Exacerbations 0-1/year ≥2/year


• Maintain current step • Regular follow-up every 1-6 months to maintain control • Consider step down if well controlled for at least 3 months

• Step up (1 step); and • Re-evaluate in 2-6 weeks • For side effects, consider alternative treatment options

• Consider short course of oral systemic corticosteroids • Step up 1-2 steps, and • Re-evaluate in 2 weeks • For side effects, consider alternative treatment options

The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient’s/caregiver’s recall of previous 2-4 weeks and by spirometry or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether patient’s asthma is better or worse since the last visit. Key: FEV1 = forced expiratory volume in 1 second; PEF = peak flow; ACT = Asthma Control Test (recommended by MaineHealth AH! Asthma Health Program); EIB = exercise-induced bronchospasm; OCS = oral corticosteroid.

Determining Asthma Control ≥12 years

Determining Asthma Control <12 years / ≥12 years


Medications Dosage Form Adult Dose Child Dose Comments Inhaled Corticosteroids (see Estimated Comparative Daily Dosages for Inhaled Corticosteroids) Systemic Corticosteroid Methylprednisolone (Medrol) Prednisolone (Prednisolone, Pediapred, Orapred)

2, 4, 8, 16, 32mg tablets 5mg tablets, 5mg/5cc, 15mg/5cc, 10 & 15mg oral dissolving tablets

7.5-60mg daily in a single dose in a.m. or qod as needed for control

0.25-2mg/kg daily in a single dose in a.m. or qod as needed for control

Prednisone (Deltasone) 1, 2.5, 5, 10, 20mg tablets

Leukotriene Modifiers Leukotriene Receptor Antagonists: Montelukast (Singulair) Zafirlukast (Accolate) 5-Lipoxygenase Inhibitor: Zileuton (Zyflo)

4mg oral granules, 4 or 5mg chewable tablet, 10mg tablet 10 or 20mg tablet

600mg tablet

10mg qhs 20mg tablet bid 2,400mg daily (divided bid if sustained release tablet)

4mg qhs (6 mos-5yrs) 5mg qhs (6-14yrs) 10mg qhs (>14yrs) 7-11 yrs: 10mg tablet bid N/A

Monitor for signs and symptoms of hepatic dysfunction For zileuton, monitor hepatic enzymes (ALT)

Combination Medication Fluticasone/Salmeterol (Advair) Budesonide/Formoterol (Symbicort) HFA MDI

DPI 100mcg/50mcg, 250mcg/50mcg, 500mcg/50mcg HFA 45mcg/21mcg, 115mcg/21mcg, 230mcg/21mcg 80mcg/4.5mcg, 160mcg/4.5mcg

1 inhalation bid; dose depends on asthma severity 2 inhalations bid; dose depends on asthma severity 2 inhalations bid; dose depends on asthma severity

5-11yrs: 100mcg/50mcg, 1 inhalation bid N/A N/A

100/50 DPI or 45/21 HFA for patients not controlled on low- to medium-dose ICS 250/50 DPI or 115/21 HFA for patients not controlled on medium- to high-dose ICS 80/4.5 for patients who have asthma not controlled on low- to medium-dose ICS 160/4.5 for patients who have asthma not controlled on medium- to high-dose ICS

Inhaled Long-Acting Beta2 –Agonists Salmeterol (Serevent) Formoterol (Foradil)

DPI 50mcg/puff DPI 12mcg/single-use capsule

1 blister q 12 hours 1 capsule q 12 hours

1 blister q 12hrs (approved for children ≥4 yrs) 1 capsule q 12 hrs (children ≥5yrs)

Should not be used for acute symptom relief or exacerbations. Use only with inhaled corticosteroids (ICS).

Cromolyn Cromolyn (Intal) MDI 1mg/puff

Nebulizer 20mg/ampule 2 puffs tid-qid 1 ampule tid-qid

2 puffs tid-qid (children ≥5yrs) 1 ampule tid-qid (children >2yrs)

May be used as exercise pre-treatment.

Methylxanthines Theophylline (Theo-Dur, Uniphyl) Liquid, sustained-release tablets,

and capsules Starting dose 10mg/kg/day up to 300mg max; usual max 800mg/day

Starting dose 10mg/kg/day; usual max=16kg/mg/day; (formula to calculate max dose if <1 year of age: 0.2 x (age in weeks) +5=mg/kg/day)

Serum monitoring is important (serum concentration of 5-15mcg/mL at steady state).

Usual Dosages for Long-Term Control Medications

Medications Dosage Form Adult Dose Child Dose Comments Inhaled Corticosteroids (see Estimated Comparative Daily Dosages for Inhaled Corticosteroids) Systemic Corticosteroids Methylprednisolone (Medrol) Prednisolone (Prednisolone, Pediapred, Orapred)

2, 4, 8, 16, 32mg tablets 5mg tablets, 5mg/5cc, 15mg/5cc, 10 & 15mg oral dissolving tablets

7.5-60mg daily in a single dose in a.m. or qod as needed for control

0.25-2mg/kg daily in a single dose in a.m. or qod as needed for control

Prednisone (Deltasone) 1, 2.5, 5, 10, 20mg tablets

Leukotriene Modifiers Leukotriene Receptor Antagonists: Montelukast (Singulair) Zafirlukast (Accolate) 5-Lipoxygenase Inhibitor: Zileuton (Zyflo)

4mg oral granules, 4 or 5mg chewable tablet, 10mg tablet 10 or 20mg tablet

600mg tablet

10mg qhs 20mg tablet bid 2,400mg daily (divided bid if sustained release tablet)

4mg qhs (6 mos-5yrs) 5mg qhs (6-14yrs) 10mg qhs (>14yrs) 7-11 yrs: 10mg tablet bid N/A

♣ Monitor for signs and symptoms of hepatic dysfunction

♣ For zileuton, monitor hepatic enzymes (ALT)

Combination Medication Fluticasone/Salmeterol (Advair) Budesonide/Formoterol (Symbicort) HFA MDI

DPI 100mcg/50mcg, 250mcg/50mcg, 500mcg/50mcg HFA 45mcg/21mcg, 115mcg/21mcg, 230mcg/21mcg 80mcg/4.5mcg, 160mcg/4.5mcg

1 inhalation bid; dose depends on asthma severity 2 inhalations bid; dose depends on asthma severity 2 inhalations bid; dose depends on asthma severity

5-11yrs: 100mcg/50mcg, 1 inhalation bid N/A N/A

♣ 100/50 DPI or 45/21 HFA for patients not controlled on low- to medium-dose ICS ♣ 250/50 DPI or 115/21 HFA for patients not controlled on medium- to high-dose ICS

♣ 80/4.5 for patients who have asthma not controlled on low- to medium-dose ICS ♣ 160/4.5 for patients who have asthma not controlled on medium- to high-dose ICS

Inhaled Long-Acting Beta2 –Agonists Salmeterol (Serevent) Formoterol (Foradil)

DPI 50mcg/puff DPI 12mcg/single-use capsule

1 blister q 12 hours 1 capsule q 12 hours

N/A N/A

♣ Should not be used for acute symptom relief or exacerbations. Use only with inhaled corticosteroids (ICS).

Cromolyn Cromolyn (Intal) MDI 1mg/puff

Nebulizer 20mg/ampule 2 puffs tid-qid 1 ampule tid-qid

2 puffs tid-qid (children ≥5yrs) 1 ampule tid-qid (children >2yrs)

♣ May be used as exercise pre-treatment.

Methylxanthines Theophylline (Theo-Dur, Uniphyl) Liquid, sustained-release tablets,

and capsules Starting dose 10mg/kg/day up to 300mg max; usual max 800mg/day

Starting dose 10mg/kg/day; usual max=16kg/mg/day; (formula to calculate max dose if <1 year of age: 0 2 x (age in weeks) +5=mg/kg/day)

♣ Serum monitoring is important (serum concentration of 5-15mcg/mL at steady state).

Usual Dosages for Long-Term Control Medications

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Estimated Comparative Daily Dosages for Inhaled Steroids

Low Daily Dose Medium Daily Dose High Daily Dose

Drug 0-4yrs 5-11yrs ≥12yrs and

Adult 0-4yrs 5-11yrs ≥12yrs and


Adult

Beclomethasone (QVAR) HFA: 40 or 80mcg puff NA 80-160mcg 80-240mcg NA >160-320mcg >240-480mcg NA >320mcg >480mcg

Budesonide (Flexhaler) DPI: 90 or 180mcg/inhalation NA 180-400mcg 180-600mcg NA >400-800mcg >600-1,200mcg NA >800mcg >1,200mcg

Budesonide Inhalation Suspension for Nebulization (Pulmicort Respules)

0.25-0.5mg 0.5mg NA >0.5-1.0mg 1.0mg NA >1.0 mg 2.0mg NA

Flunisolide (Aerobid) 250mcg/puff NA 500-750mcg 500-1,000mcg NA 1,000-1,250mcg >1,000-2,000mcg NA >1,250mcg >2,000mcg

Fluticasone (Flovent) HFA: 44, 110, or 220mcg/puff DPI: 50mcg/inhalation

88-176mcg NA

88-176mcg 100-200mcg

88-264mcg 100-300mcg

>176-352mcg NA

>176-352mcg >200-400mcg

>264-440mcg >300-500mcg

>352mcg NA

>352mcg >400mcg

>440mcg >500mcg

Mometasone (Asmanex) DPI: 110, 220mcg/inhalation NA 4-11yrs

110mcg 220mcg NA 4-11yrs 220mcg 440mcg NA NA >440mcg

Triamcinolone acetonide (Azmacort) 100mcg/puff NA 300-600mcg 300-750mcg NA >600-900mcg >750-1,500mcg NA >900mcg >1,500mcg

Key: DPI = dry powder inhaler; HFA = hydrofluoroalkane; MDI = metered-dose inhaler; NA = not available (either not approved, no data available, or safety and efficacy not established for this age group)

Usual Dosages for Long-Term Control Medications / Comparative Daily Dosages for Inhaled Steroids

Low Daily Dose Medium Daily Dose High Daily Dose

Drug 0-4yrs 5-11yrs ≥12yrs and



Adult

Beclomethasone (QVAR) HFA: 40 or 80mcg puff NA 80-160mcg 80-240mcg NA >160-320mcg >240-480mcg NA >320mcg >480mcg

Budesonide (Pulmicort Flexhaler) DPI: 90 or 180mcg/inhalation NA 180-400mcg 180-600mcg NA >400-800mcg >600-1,200mcg NA >800mcg >1,200mcg

Budesonide Inhalation Suspension for Nebulization (Pulmicort Respules)

0.25-0.5mg 0.5mg NA >0.5-1.0mg 1.0mg NA >1.0 mg 2.0mg NA

Ciclesonide (Alvesco) HFA* 80 mcg/ 160mcg/ inhalation NA NA 160-320 mcg NA NA 320-640 mcg NA NA >640 mcg

Flunisolide (Aerobid) 250mcg/puff NA 500-750mcg 500-1,000mcg NA 1,000-1,250mcg >1,000-2,000mcg NA >1,250mcg >2,000mcg

Fluticasone (Flovent) HFA: 44, 110, or 220mcg/puff DPI: 50mcg/inhalation

88-176mcg NA

88-176mcg 100-200mcg

88-264mcg 100-300mcg

>176-352mcg NA

>176-352mcg >200-400mcg

>264-440mcg >300-500mcg

>352mcg NA

>352mcg >400mcg

>440mcg >500mcg

Mometasone (Asmanex) DPI: 110, 220mcg/inhalation NA 4-11yrs

110mcg 220mcg NA 4-11yrs 220mcg 440mcg NA NA >440mcg

Triamcinolone acetonide (Azmacort) 100mcg/puff NA 300-600mcg 300-750mcg NA >600-900mcg >750-1,500mcg NA >900mcg >1,500mcg

Usual Dosages for Long-Term Control Medications / Comparative Daily Dosages for Inhaled Steroids

Estimated Comparative Daily Dosages for Inhaled Steroids

Key: DPI = dry powder inhaler; HFA = hydrofluoroalkane; MDI = metered-dose inhaler; NA = not available (either not approved, no data available, or safety and efficacy not established for this age group) *Dosing recommendations are estimated based on FDA package insert. No direct comparisons were available at time of publication.


Medications Dosage Form Adult Dose (≥12 years) Child Dose (0-11 years) Comments Inhaled Short-Acting Beta2-Agonists (SABA)1,2 Albuterol (ProAir/Ventolin/Proventil) HFA Pirbuterol (Maxair) CFC Levalbuterol (Xopenex) HFA

90mcg/puff, 200 puffs 200mcg/puff, 400 puffs 45mcg/puff, 200 puffs

2 puffs q 4-6hrs prn or 10-15min before exercise 2 puffs q 4-6hrs prn

2 puffs q 4-6hrs prn Safety and efficacy not established for children <12yrs 5-11yrs: 2 puffs q 4-6hrs prn

Albuterol Levalbuterol (Xopenex)

Nebulizer Solution 0.63mg/3mL 1.25mg/3mL 2.5mg/3mL 5mg/mL (0.5%) 0.31mg/3mL 0.63mg/3mL 1.25mg/0.5mL 1.25mg/3mL

2.5-5mg q 4-8hrs prn 0.63mg-1.25mg q 8hrs prn

0-4 yrs: 0.63-2.5mg q 4-6hrs prn 5-11 yrs: 1.25-5mg q 4-8hrs prn 0-4 yrs: 0.31-0.63mg q 4-6hrs prn 5-11yrs: 0.31-0.63mg q 4-6hrs prn

1 Regular use exceeding 2 days/week for symptom control (not prevention of EIB) indicates the need for additional long-term control therapy.

2 For an exacerbation at home, up to 2 treatments

20 minutes apart of MDI (2-6 puffs) or nebulizer may be used, and if good response, continued q 4hrs as needed for 24-48hrs. If incomplete response, contact doctor.

Anticholingerics:3 lpatropium (Atrovent) Ipratropium with albuterol (Duoneb)

Nebulizer Solution 0.25mg/mL (0.025%) Nebulizer Solution 0.5mg/3mL ipratropium bromide and 2.5mg/3mL albuterol

0.25mg q 6hrs 3mL q 4-6hrs

NA NA

3 Evidence is lacking for anticholinergics producing added benefit in long-term therapy.

Systemic Corticosteroids: Prednisolone4 Prednisone4 Methylprednisolone acetate5

10 & 15mg oral dissolving tabs (Orapred ODT) 5mg/5cc (Pediapred, Prelone) 15mg/5cc (Prelone, Orapred) 1, 2.5, 5, 10, 20, 50mg tabs Repository Injection 40mg/mL 80mg/mL

Short course: 40-60mg/day as single or 2 divided doses for 3-10 days 240mg IM once

Short course: 1-2mg/kg/day max 60 mg/day for 3-10 days 0-4yrs: 7.5 mg/kg IM once 5-11yrs: 240 mg IM once

4 The burst should be continued until patient

achieves 80% PEF personal best or symptoms resolve; usually 3-10 days, may be longer. May consider tapering for patients requiring >6 days of therapy.

5 May be used in place of a short burst of oral

corticosteroids in patients who are vomiting or if adherence is a problem.

Usual Dosages for Quick-Relief Medications


Emergency Treatment for Acute Exacerbations - Mild

Assess patient. Obtain temperature, pulse, respiration, weight, height; obtain FEV1/PEF if >5 years old (as appropriate)

Administer inhaled albuterol 2.5mg at 20 minute intervals via nebulizer or albuterol MDI, 2-8 puffs with valved holding chamber (spacer). Up to 3 treatments via nebulizer or MDI may be given. If using a Breath Actuated Nebulizer (BAN), only one treatment may be needed.

Check pulse, respiration, chest exam, FEV1 or peak flow 20 minutes after inhaled treatment completed.

If patient improves and: • Response sustained 60 minutes after last treatment • No wheeze, no shortness of breath • Normal physical exam

Consider treating any co-morbities (e.g., otitis media, sinusitis, allergic rhinitis, gastroesophageal reflux (GER))

Follow guideline for moderate exacerbation

Patient education to be initiated prior to discharge. Begin education with emphasis on: • Basic facts about asthma • Roles of medications • Skills using inhalers, peak flow meters, and spacer devices • Environmental control measures • Action plans – home and school If patient is in a smoking environment, encourage tobacco treatment program at 1-800-207-1230, The Maine Tobacco Helpline. Consider referral to a certified asthma educator for on-going patient education. In Portland, call 207-662-3325.

If patient does not improve

• Discharge patient to home on inhaled albuterol q 4-6hrs for 24-48hrs and then q 4-6hrs prn or as directed by healthcare provider.

• If the patient has recently been on oral steroids, consider treatment with oral steroids (up to 1-2 mg/kg/day, maximum dose 60mg in children, 80mg in adults).

• Consider initiating inhaled corticosteroids (if persistent asthma). • Follow-up by phone or office visit with primary care provider within 1-5 days.

• Patient is alert and oriented, speaks in sentences, is dyspneic only with activity, may have slight expiratory wheezing, and is tachypneic; and/or, • FEV1/peak flow ≥70% of predicted or personal best • Oxygen saturation >95% (test not usually necessary) These patients rarely require inpatient treatment for asthma (i.e. hospitalization). When classifying severity, consider therapy received prior to acute visit and response to initial treatments.

Usual Dosages for Quick-Relief Medications / Emergency Treatment for Acute Exacerbations - Mild


Emergency Treatment for Acute Exacerbations - Moderate

Good Response • FEV1 or PEF>70% • Sustained response 60 minutes after treatment • No dyspnea or oxygen requirement • Normal exam

Incomplete Response • FEV1 or PEF 40-69% and/or, • Mild to moderate symptoms

Poor Response • FEV1 or PEF<40% • Severe symptoms • Drowsy, confused

• Continue treatment with albuterol q 1-3hrs • Continue systemic corticosteroids (0.5-1mg/kg

q 12hrs for the initial 48hrs if hospitalized, then re-evaluate; usual maximum dose=60mg/day in children, 80mg/day in adults)

• Treat co-morbidities • Consider hospitalization and follow available

inpatient guidelines

Follow guidelines for severe exacerbation and admit to ICU

Discharge to home: • Inhaled albuterol q 4-6hrs for 24-48 hrs and then q 4-

6hrs prn or as directed by healthcare provider • Continue controller medications and if not on inhaled

corticosteroids (ICS) consider prescribing • Oral corticosteroids (OCS): up to 1-2mg/kg/day in 1 or

2 divided doses for 3-10 days (maximum=60mg for children, 80mg for adults); consider tapering for patients requiring >6 days of OCS

• Follow-up by phone or office visit with primary provider within 24-48hrs

Patient education to be initiated prior to discharge; begin education with emphasis on: • Basic facts about asthma • Roles of medications • Skills using inhalers, peak flow meters, and spacer devices

• Patient is agitated, not playful, and speaks in phrases. An infant may have a softer, shorter cry and difficulty feeding. Patient is using accessory muscles, may have loud wheezing, and is tachypneic; and/or,

Administer albuterol 2.5 mg at 20 minute intervals via nebulizer or albuterol MDI, 2 - 8 puffs with valved holding chamber (spacer); may consider adding ipratropium. Up to 3 treatments via nebulizer or MDI may be given over the 1st hour and then spread to every 1-3 hours if improvement is noted.

• Environmental control measures • Action plans – home and school If patient is in smoking environment, encourage tobacco treatment program at 1-800-207-1230, The Maine Tobacco Helpline. Consider referral to a certified asthma educator for on-going patient education. In Portland, call 207-662-3325.

Treat co-morbidities (e.g., pneumonia, otitis media, sinusitis, allergic rhinitis, gastroesophageal reflux (GER))

Assess patient. Obtain temperature, pulse, respiration, weight, height; obtain FEV1/PEF if >5 years old (as appropriate)

Corticosteroids (oral prednisone or equivalent) 1-2 mg/kg up to a max of 60 - 80 mg. Consider IV steroids if patient cannot tolerate oral medication.

If using a breath actuated nebulizer (BAN), fewer treatments may be needed.

• FEV1/peak flow 40-69% of predicted or personal best • Oxygen saturation 90-95% (test not usually necessary)

Check patient’s pulse, respirations every hour.


Emergency Treatment for Acute Exacerbations – Severe

Emergency Treatment for Acute Exacerbations – Moderate / Severe

Assess patient. Obtain vital signs, weight, and height (as appropriate) in ED. Consider FEV1/peak flow if >5 years old. FEV1/peak flow may be difficult or impossible to measure due to significant dyspnea and cough. Therefore, FEV1/peak flow may not be appropriate in very severe cases of obvious airway compromise or cyanosis.

• Patient is breathless at rest. Dyspnea interferes with conversation (e.g. speaks in words). An infant will stop feeding. Patient is using accessory muscles, has suprasternal retractions, may or may not have loud wheezing (throughout inhalation and exhalation), and is tachypneic

• FEV1/peak flow <40% of predicted or personal best • Oxygen saturation <90%

Administer oxygen to keep saturation >90%. Administer moderate to high dose albuterol plus ipratropium nebulizer q 20min x 3, or albuterol continuously for 1 hour. BAN (breath actuated nebulizer) is recommended to increase delivery of nebulized medications in severe exacerbations.

Corticosteroids (oral prednisone or equivalent) 1-2mg/kg up to a max of 60-80 mg. Consider IV corticosteroids if patient cannot tolerate oral medication.

Repeat vital signs (pulse and respiratory rate) q 15 minutes. Continuous pulse oximetry.

Good Response Incomplete Response Poor Response • FEV1 or PEF>70% • FEV1 or PEF 40-69% • FEV1 or PEF <40% • Sustained response 60mins after treatment • No dyspnea or oxygen requirement • Improved physical exam

• Mild to moderate symptoms • PCO2>42mm Hg • Severe symptoms • Drowsy, confused • Continue supplemental oxygen

• Continue treatment with albuterol and ipratropium q 1-3hrs (while in the ED); or continuous albuterol Admit to ICU – With orders for: • Consider hospitalization

• Continue systemic corticosteroids (0.5-1mg/kg q 6-12hrs: usual max dose=60mg/day in children, 80mg/day in adults)

• Supplemental oxygen • Continue oral corticosteroids 0.5-1mg/kg q 12hrs for 3-10 days (max dose=60mg for children, 80mg for adults); consider tapering for patients requiring >6 days of OCS

• Corticosteroids IV 1 mg/kg q 12 hours • Consider arterial line for serial ABGs • Treat co-morbidities • Albuterol nebs hourly or continuous at • Hospitalize and follow available inpatient guidelines 0.15-0.5mg/kg/hr (maximum of 10-15mg/hr) • Wean nebulized albuterol to q 3-4hrs • Consider adjunctive therapies • Patient education

• If not on inhaled corticosteroids (ICS), consider initiation of an ICS ICU Admission Criteria

• Intubated or pending intubation • pCO2 greater than 55 • Requiring more than 50% FiO2 • Requiring nebulized therapies more frequently than q 2hrs • Altered mental status • Acute pneumothorax • Use of adjunctive therapies – heliox, terbutaline, magnesium


MaineHealth, a not-for-profit health system serving the people of southern, western and central Maine, is working with communities and organizations around the state to improve the care of children and adults with asthma through the AH! Asthma Health Program. A key goal of the program is to improve the clinical care of asthma by supporting the consistent use of nationally developed guidelines in the diagnosis and management of asthma. To support this effort, the AH! Program created this flip chart summarizing current recommendations for asthma care. The AH! Asthma Health Program efforts have been fueled by a multidisciplinary group of clinicians representing nursing, respiratory therapy, public health, primary care physicians, pulmonary and allergy/immunology subspecialists. This chart was adapted from the National Heart, Lung, and Blood Institute (NHLBI) National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007. Some recommendations reflect the local expert opinion of the AH! Asthma Health Program clinicians. We would like to give special thanks to the following people for their efforts in the production of the 2008 version of this flip chart: Dr. Barbara Chilmonczyk (Allergist/Immunologist); Dr. Jennifer Jewell (Hospitalist); Rhonda Vosmus, RRT; Donna Levi, M.S.; and Joel Richard. These guidelines were developed for healthcare professionals who provide asthma care to patients. They are intended as a guide for care, but are not intended to replace providers’ clinical judgment or to establish a single protocol. Some clinical problems may not be adequately addressed by these guidelines. As always, clinicians are urged to document management strategies. For questions or more information, please contact the AH! Asthma Health Program Manager at tel. 207-541-7566. These guidelines are also available on the web at www.mainehealth.org/AH.

2008, rev 2009. Reproduction of any MaineHealth document without consent is expressly prohibited.


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